| National Provider Identifier [NPI]: | 1083919898 |
| Last Name Of The Provider | SAMPLE |
| First Name Of The Provider | DENISE |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | NP-C |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 6905 KNIGHTDALE BLVD |
| Street Address 2 Of The Provider | SUITE 106 |
| City Of The Provider | KNIGHTDALE |
| Zip Code Of The Provider | 275456505 |
| State Code Of The Provider | NC |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 46 |
| Number Of Services | 463 |
| Number Of Medicare Beneficiaries | 172 |
| Total Submitted Charge Amount | 57641 |
| Total Medicare Allowed Amount | 21238.31 |
| Total Medicare Payment Amount | 14314.4 |
| Total Medicare Standardized Payment Amount | 18351.46 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 35 |
| Number Of Medicare Beneficiaries With Drug Services | 33 |
| Total Drug Submitted ChargeAmount | 1183 |
| Total Drug Medicare AllowedAmount | 839.63 |
| Total Drug Medicare PaymentAmount | 751.76 |
| Total Drug Medicare Standardized Payment Amount | 751.76 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 42 |
| Number Of Medical Services | 428 |
| Number Of Medicare Beneficiaries With Medical Services | 172 |
| Total Medical Submitted Charge Amount | 56458 |
| Total Medical Medicare Allowed Amount | 20398.68 |
| Total Medical Medicare Payment Amount | 13562.64 |
| Total Medical Medicare Standardized Payment Amount | 17599.7 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 28 |
| Number Of Beneficiaries Age 65 to 74 | 87 |
| Number Of Beneficiaries Age 75 to 84 | 40 |
| Number Of Beneficiaries Age Greater 84 | 17 |
| Number Of Female Beneficiaries | 106 |
| Number Of Male Beneficiaries | 66 |
| Number Of Non Hispanic White Beneficiaries | 139 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 156 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 16 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 21 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 8 |
| Percent Of With Depression | 26 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 37 |
| Percent Of With Hypertension | 70 |
| Percent Of With Ischemic Heart Disease | 31 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 32 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 9 |
| Average HCC Risk Score Of Beneficiaries | 1.062 |